Quality Improvement

Despite the resources and investments made in the health sector over the last few years, Nigeria continues to record suboptimal health outcomes. Marginal improvements in some indices, namely maternal mortality and under-5 deaths have been recorded, but Nigeria still accounts for 14% of global maternal mortality figures and loses 528 neonates to largely preventable causes daily.

In the National policy landscape, Nigeria has historically lacked a clear strategy on healthcare quality and no agency was formally tasked with implementing and monitoring quality standards. Furthermore, patient satisfaction which is globally recognised as an indicator of quality has historically been grossly ignored across health facilities in the country. These have contributed to the poor quality of care and consequently poor health outcomes in Nigeria.

In order to tackle these multi-faceted issues that have contributed to dismal country level statistics on health outcomes, HSDF established the quality improvement team to address the issues within the system as well as those hampering the macro-environment.

Our Goals

The overarching goal of the HSDF quality improvement team is to drive measurable improvements in the national health outcomes related to maternal mortality, neonatal deaths and patient satisfaction.

Our Approach

To achieve the overarching goal of health outcome improvements, HSDF adopts a two-pronged approach designed to close the quality gaps in the healthcare landscape of Nigeria:

Advocacy and collaboration with development partners and the public sector

HSDF collaborates with the ministry of health, development partners and other government agencies to drive policy changes that directly impact quality outcomes for the broader society. HSDF adopts a hands-on approach that involves comprehensive needs assessments, joint development of applicable frameworks and documentation, and deployment of impact-oriented tools to key stakeholders. Some key achievements on this front include the development of a national quality strategy plan which is expected to be transformative to the quality landscape of Nigeria once ratified by the Federal Ministry of health, and subsequently deployed across the country.

Establishing and implementing quality improvement collaboratives amongst frontline healthcare providers

In addition to driving top-down change from policy makers, HSDF engages in internal process overhauls for frontline healthcare providers towards the same goal. This is achieved through a collaborative learning platform and the ‘model for improvement’ methodology for continuous quality improvement. The collaborative learning platform creates an environment for shared learning, best practice exchange and continuous capacity development of frontline healthcare providers.

Results

HSDF, through the implementation of the strategic approach mentioned above, has recorded progress which is greatly beneficial to the health system. HSDF has become a forerunner for quality in health care and has achieved system level changes and accomplishments, some of which are listed below:

Development of a Quality Strategy Document:

Following consultations with over 140 stakeholders in the health sector, at Federal, State and LGA levels, the SOML PDU working with the leadership of the Director of Hospital Services  developed a draft Nigerian National Healthcare Quality Strategy. This document is currently awaiting ratification from the FMOH.

SOML/Sure-P Quality Project:

SOML and the NPHCDA/SURE-P MCH collaborated to improve quality of care at the PHC level through building local capacity for Quality Improvement. An Impact Evaluation (IE) is also embedded in the process to test the program’s effectiveness. The project focused on improving patient safety and clinical effectiveness at the lowest level of care. 48 facilities across 6 states were part of the project. The project has since been suspended following the conclusion of the SureP project.

Service Delivery Indicator Survey:

In collaboration with the World Bank, a baseline assessment of quality in about 2400 facilities within Nigeria was carried out, to ascertain the extent and nature of service delivery through a service delivery indicator survey. This is currently routinely carried out on an annual basis.

The Quality Improvement Collaboratives:

Using the quality improvement collaborative method, HSDF has recorded the following gains in two Nigerian states:

Lagos state:

  • Maternal case fatality rates across all the facilities have continuously declined since September 2015
  • Partograph use in all facilities has increased by 50% across the board and by 70% in primary health care centres.

Imo state:

  • Partograph use has increased from 0% to 50% in all participating facilities
  • Initiation of breastfeeding within 1 hour has also increased in all the facilities by 15 %

Ongoing work

HSDF is currently driving the quality improvement collaborative process in 2 states (Lagos and Imo state), with implementation in Niger State scheduled to begin in 2016.The quality improvement collaborative process is structured into two distinct phases.

Learning sessions

Every quarter, the HSDF quality team invites quality improvement teams from participating facilities to learning sessions that cover evidence-based clinical practice and advances in quality improvement methodologies. These sessions provide a forum for idea exchanges between facilities, and result in the development of new strategies for quality improvement that can be implemented by facilities.

Implementation periods

During the implementation period, the participating facilities implement the new strategies designed during the learning sessions. The HSDF team is actively involved in:

  • Continuous coaching and mentoring of the QI team members by HCQI advisors through strategic and technical assistance
  • Setting measurable targets, generating new ideas, testing small changes and collecting relevant data
  • Evaluating the changes and using data for corrective action